Daycare ApplicationPlease complete the application and one of our staff members will be in touch! Program Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Child's Full Name * First Name Last Name Date of Birth * xx/xx/xxxx Child's Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Name of Person Enrolling Child * First Name Last Name Relationship to Child * Parent Guardian Caretaker Relative Phone Numbers of Person Enrolling Child: * Ok to Text * Yes No Email * Address of Person Enrolling Child * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact 1 * (Primary Contact) First Name Last Name Authorized to Pickup Child * Yes No Primary Phone Number * (###) ### #### Other Phone Number & Email * Emergency Contact 2 First Name Last Name Authorized to Pickup Child Yes No Primary Phone Number (###) ### #### Other Phone Number & Email Child's Full Name * First Name Last Name Date of Birth * Check boxes below to indicate if your child has any special needs/services: * None Early Intervention/Special Education Occupational Therapy Speech/Language Physical Therapy Other: Allergies (Please Specify) Child's Primary Physician's Name/Group * Phone Number * (###) ### #### Preferred Hospital * Phone Number * (###) ### #### Child's Dental Care * Phone Number * (###) ### #### Child healthcare information is available by calling tool-free 1-800-698-4543 or the NYS Health Marketplace website: http://nystateofhealth.ny.gov/ I consent to emergency medical treatment for my child. * Yes No I consent for my child to take part in neighborhood trips (i.e. library, park, and playground) away from the program under proper supervision. * Yes No I understand the program may need additional permissions for situations such as transportation, medication, release of information, and field trips. * Yes No I provided information on my child's special needs to the program to assist in caring for my child. * Yes No I understand the program must give parents, at the time of enrollment of a child, a written policy statement as required by regulation. * Yes No I agree to review and update this information whenever a change occurs and at least once every year. * Yes No Signature - Parent or Person(s) Legally Responsible * Today's Date * MM DD YYYY Thank you!
